Module 1 Flashcards

1
Q

Florence Nightingale

A

Founder of Nursing
Noticed relationship between environment and health

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2
Q

Dorothea Dix

A

Established Nurse Corps of the United States Army

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3
Q

Clara Barton

A

Organized the American Red Cross

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4
Q

Peplau’s theory

A

Interpersonal relations with patients. Nurse must become their counselor and caretaker and tailor to individual needs of the patient

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5
Q

Henderson’s theory

A

Holistic care, 14 major needs
Role of nurse is to assist in meeting the patients basic needs when they cannot do so independently

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6
Q

Roger’s theory

A

Patients are whole, and constantly interacting with their environment.
Role of nurse is to facilitate change in the patients energy field, and maintain balance.

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7
Q

Orem’s theory

A

Surrounding self care deficit.
Nurses are use assessment, diagnosis, planning, implementation, and evaluation to find patient’s self care deficit and develop and implement care.

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8
Q

Neuman’s theory

A

Health Care System Model.
Focuses on human stressors and emphasizes need to cope with them.

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9
Q

Roy’s theory

A

Adaptation Model.
Focuses on how patients adapt to their environment, so the role of nurses is to assist in adapting to their new environment.

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10
Q

Maslow’s hierarchy

A

From bottom to top:

Physiological needs - food, water, breathing, shelter, clothing sleep

Safety & security - health, employment, family, property

Love and belonging - friends, family, intimacy, connection

Self esteem - confidence, respect, achievement

Self actualization - morality, creativity acceptance

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11
Q

CABD

A

Chest compression
Airway
Breathing
Defibrillation

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12
Q

QSEN

A

Quality and Safety Education for Nurses

Purpose: prepare nurses with competencies necessary to improve quality and safety of Healthcare

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13
Q

Patient centered care

A

Patient is in control
Nurses provide care based on patient’s preference, values, and needs

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14
Q

Health assessment

A

Establish a database
Identify patient risk factors and strengths/limitations
Compare assessment with baseline norms
Components: health history and physical assessment

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15
Q

Health history

A

First step in establishing trust.

Medication
Past surgery
Family history
Personal/social history
Review of systems

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16
Q

Physical exam

A

Head to toe - organized, comprehensive

Body systems - Focused on specific systems

Functional health patterns - focus on effects of health or illness on patient’s QOL
Includes holistic care

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17
Q

Assessment examination order

A

NON-ABDOMINAL: Inspection, palpation, percussion, auscultation

ABDOMINAL: inspection, auscultation, percussion, palpation

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18
Q

Bell vs Diaphragm

A

Bell - low pitched sounds (vascular sounds, heart murmur, bruit)

Diaphragm - high pitched sounds (B/P, heart sounds, lung sounds, abdominal)

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19
Q

Primary vs secondary sources

A

Primary: from the patient themselves
Secondary: anyone else

20
Q

Subjective vs Objective data

A

Subjective: Verbal, from the patient
Objective: signs detected by the nurse during examination

21
Q

Sounds of percussion

A

Tympany - loud and drum like - air filled structure like intestine
Resonance - low pitched - air filled hollow organ
Hyperresonance - loud and booming - air around organ
Dullness - thud and muffled - fluid or solid organs
Flatness - soft and short. - solid tissue and bone

22
Q

Space and territoriality zones

A

Intimate zone - 0 to 18 in
Personal zone - 18 in to 4 ft
Social zone - 4 to 12 ft
Public zone - 12ft and beyond

Always explain to patient what you are doing first

23
Q

Phases of nurse-client relationship

A

Orientation/initiating - establishing trust/rapport
Working - The patient is an active participant
Termination - closure of the relationship

24
Q

Hand-off communication (SBAR)

A

Situation
Background
Assessment
Recommendation

25
Q

Communication facilitators

A

Open-ended questions
-Allows patient to talk. Start with what, how, tell me more

Validating
-What the nurse believes the patient said

Clarifying
-Offers back to the speaker the essential meaning

Reflective
-Focuses on patient’s feelings

Silence
-Allows client time to think

General leads
-Encourages client to talk and indicates interest

Direct question
-Obtains more info about topic

Providing information
-Informs the patient of facts needed to understand situation

Sharing observations
-Calling patient’s attention to what is observed

Offering self
-Willingness to spend time with patient

26
Q

responses to avoid in therapeutic communication

A

False reassurance
* Closed-ended questions
* Giving advice
* Sharing personal opinions
* Changing the subject
* Using personal terms of endearment
* Asking for explanations: avoid questions
that begin with “WHY”

27
Q

Average temperature when taken orally

A

98.6F and 37C

28
Q

4 ways of heat loss

A

Radiation - transfer of heat into environment (walking into a refrigerator)
Conduction - Transfer of heat from body to another surface
Convection - dispersion of heat, like a fan on the body
Evaporation

29
Q

Why shouldn’t we give Asprin to someone under 16?

A

May cause Reye’s syndrome

29
Q

Hyperthermia temp

A

~102.2F / 39C

30
Q

Hypothermia temp

A

Less than 95F / 35C

31
Q

Movement of ear for tympanic thermometers

A

Adults: back, up, out
Children: back, down

32
Q

Pulse strengths

A

0 - absent
+1 - diminished, weak
+2 - normal
+3 - bounding

33
Q

Respiration rates

A

Norm: 12-20
Tachypnea - greater than 24
Bradypnea less than 10

34
Q

Normal pulse oximetry

A

95-100%

35
Q

Pain assessment: OLDCART

A

Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment

36
Q

What is the assessment tool for pain?

A

Wong-Baker Tool

37
Q

What is a nosocomial infections

A

Hospital acquired

38
Q

When do you wash hands

A

When hands are visibly soiled
Working with high risk clients
Working with body fluids or spore forming organisms

39
Q

When should vitals be taken

A
  • On admission
  • As part as the physical assessment
  • Routine monitoring
  • With any change in the patient’s health
    status
  • Before & after surgery or invasive
    procedures
  • In ongoing care to detect improvement in
    patient condition
  • Before discharge or transfer to another
    unit
40
Q

What is erythema

A

Redness of skin, common in pressure injuries

41
Q

Lowest and highest Braden score?

A

6 - 23

42
Q

Petechiae

A

Pin point red or purple spots
May indicate blood clotting disorders, drug reactions or liver disease

43
Q

Edemas

A

+1 - 2mm immediate rebound
+2 - 4mm couple seconds to rebound
+3 - 6mm 10-20 seconds to rebound
+4 - 8mm 20+ seconds to rebound

44
Q

ABCDE for melanoma

A

Asymmetry
Border irregularity
Color varies from blue to black
Diameter greater than 6mm
Evolving over time

45
Q

Hirsutism

A

Increased hair growth on upper lip, chin, cheeks. Check for this in women

46
Q

Clubbing of fingers caused by?

A

chronic pulmonary disorders